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The nurse assesses the client after the dose of albuterol and documents the findings in the chart.

Exhibits

Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Allow the client to take a position of comfort

Discuss aggressive respiratory treatment options

Prepare for deep tracheal suctioning

Discuss with the client potential asthma triggers

Wean the supplemental oxygen

Obtain a sputum culture

Monitor the oxygen saturation

Consider positive pressure ventilation

Answer and Explanation

Correct Answer : A,D,G

A.   Allowing the client to find a comfortable position can help reduce anxiety and promote relaxation, which can be beneficial during an asthma exacerbation.
B.   While the patient is currently receiving treatment with albuterol and oxygen, discussing aggressive respiratory treatment options may not be necessary at this moment unless the patient's condition deteriorates and requires escalation of care.
C.   Deep tracheal suctioning is not indicated based on the current assessment findings unless there is a specific clinical indication such as excessive secretions or respiratory distress.
D.   Identifying and discussing potential triggers is important for asthma management. This helps the client understand what factors might exacerbate their asthma and how to avoid them in the future.
E.   Since the patient's oxygen saturation is still below target (91% on room air), weaning the supplemental oxygen is not appropriate at this time. The oxygen therapy should be continued as per the titration orders to maintain saturation above 94%.
F.   Obtaining a sputum culture is not typically indicated in acute asthma exacerbations unless there is suspicion of a secondary infection or if the patient develops persistent fever and productive cough.
G.   Continuously monitoring oxygen saturation is crucial to ensure it remains above 94%. This helps gauge the effectiveness of treatment and ensures the patient's respiratory status is stable.
H.   Positive pressure ventilation is a more advanced intervention and is not indicated based on the current assessment findings. It would only be considered if the patient's condition worsens despite maximal medical therapy.

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Correct Answer is A

Explanation

Rationale

A. Osteoarthritis is characterized by the gradual destruction of joint cartilage. Cartilage serves as a cushion between the bones in a joint, and its deterioration leads to pain, stiffness, and reduced joint function. As the cartilage wears away, bones may rub directly against each other, causing further pain and damage.

B. Osteoarthritis is primarily a degenerative condition rather than an inflammatory one. While mild inflammation can occur in OA, it is not as prominent as in autoimmune conditions like rheumatoid arthritis. In OA, inflammation is secondary to cartilage damage rather than a primary driver of the disease process.

C. Loss of bone mineral density is more characteristic of osteoporosis, a condition where bones become weak and brittle. Osteoporosis involves a decrease in bone mass throughout the skeleton, whereas osteoarthritis specifically targets the joints and affects cartilage rather than bone density.

D. An infectious process in the synovial fluid could indicate septic arthritis, which is characterized by infection in the joint space. This is typically associated with acute symptoms such as severe joint pain, swelling, warmth, and fever.

A. Iron-rich meats. B. Fresh fruits and vegetables. C. Water and herbal teas. D. Low fat dairy products.

Correct Answer is D

Explanation

Rationale

A. Iron-rich meats are beneficial for overall health, particularly for maintaining hemoglobin levels in the blood. However, they are not specifically known for their role in preventing osteoporosis. Iron is important for transporting oxygen in the blood but does not directly impact bone health.

B. Fresh fruits and vegetables are excellent sources of vitamins, minerals, and antioxidants. They contribute to overall health and well-being but are not specifically known for their direct impact on bone health unless they are rich in certain nutrients like vitamin C (found in citrus fruits and peppers) and vitamin K (found in leafy greens like spinach and kale), which can indirectly support bone health.

C. Water is essential for overall hydration and health, but it does not provide specific nutrients directly beneficial for bone health. Herbal teas can contribute to hydration and provide some antioxidant benefits, but they do not have a direct impact on osteoporosis prevention.

D. Low-fat dairy products such as milk, yogurt, and cheese are rich sources of calcium and vitamin D, which are crucial for bone health. Calcium is a primary mineral in bones, and vitamin D helps the body absorb calcium. These nutrients are essential for maintaining bone density and strength, thereby reducing the risk of osteoporosis.

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The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Nursing Test Bank

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An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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The nurse assesses the client after the dose of albuterol and documents the findings in the chart.

Exhibits

Which action(s) should the nurse plan for the rest of the shift? Select all that apply.